Sleep and quality of life in children with traumatic brain injury and ADHD

Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury

STUDY OBJECTIVES

We aimed to investigate the use of sleep efficiency (SE) as a measure of sleep disturbance in infants and toddlers with acquired brain injury (ABI) and evaluate associations between SE and child health-related quality of life and family outcomes.

METHODS

Retrospective cohort study of 101 children ages 3-36 months who survived critical care for ABI. SE was quantified from the Brief Infant Sleep Questionnaire as a ratio of nighttime sleep to total time in bed; poor SE was defined as < 80%. Outcome measures included the Pediatric Quality of Life Inventory Core Total Score (health-related quality of life) and Family Impact Module Total Score. Spearman's correlation quantified associations between SE and outcomes. Multivariable linear regression tested association between poor SE and health-related quality of life controlling for significant covariates (age, diagnosis, comorbidities, worsening Functional Status Scale).

RESULTS

Following ABI, median SE was 91.7 (interquartile range = 83.3, 95.5). Nineteen (19%) children had poor SE (< 80%). SE correlated significantly with quality of life (Spearman's correlation = .307) and Family Impact Module (Spearman's correlation = .309; both P < .01). When controlling for covariates, poor SE significantly increased risk for lower health-related quality of life (β-coefficient = -7.0; 95% confidence interval= -13.4, -0.6).

CONCLUSIONS

One in five infants and young children with ABI have poor SE that is associated with poorer child and family health outcomes. Our study underscores the potential importance of sleep following ABI to optimize recovery and the need for additional investigation of SE in infants and young children.

CITATION

Klapp JM, Hall TA, Riley AR, Janzen D, Williams CN. Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury. J Clin Sleep Med. 2024;20(1):75-83.

The Impact of Sleep Disturbances on Health-Related Quality of Life in Children With Acquired Brain Injury After Critical Care

BACKGROUND

Over 60,000 children with acquired brain injury (ABI) in the United States require admission to pediatric intensive care units annually. Over 50% suffer sleep-wake disturbances (SWDs) months after discharge. Given the importance of sleep to brain repair, we hypothesized that SWD would be associated with poorer health-related quality of life (HRQOL).

METHODS

Cross-sectional analysis of prospectively collected data in children with ABI aged 3 to 18 years evaluated 1 to 3 months after critical care hospitalization (N = 151). SWD measured by Sleep Disturbances Scale for Children and defined as T-score ≥60 signifying moderate-severe risk of sleep disorders. HRQOL measured by Pediatric Quality of Life Inventory, which defines minimal clinically important difference as 4.5 points in total score. Secondary outcomes included scores for Physical, Emotional, Social, and School Function domains. SWD groups were compared with Mann-Whitney tests. Multiple linear regression evaluated association between SWD and HRQOL controlling for patient and ABI characteristics. Significance was defined as P < 0.05.

RESULTS

SWDs were present in 66% (n = 100). HRQOL total score was significantly lower in children with SWD (median = 70; interquartile range [IQR] = 54, 80) versus without (median = 85; IQR = 67, 94; P < 0.001). Median scores in emotional, social, and school domains were significantly lower in SWD group (all P < 0.01). When controlling for age, sex, critical care interventions, preadmission comorbidities, and decline from preadmission Functional Status Scale, presence of SWD significantly reduced HRQOL total score nearly three times minimal clinically important difference (β-coefficient = -12.1; 95% confidence Interval = -17.9, -6.2).

CONCLUSIONS

SWD following ABI significantly decreased HRQOL overall and across multiple health domains. Sleep is potentially modifiable. Our data support future studies targeting sleep to improve outcomes after ABI.

Neurocognitive functioning and health-related quality of life of children after pediatric intensive care admission: a systematic review

OBJECTIVE

This study systematically reviewed recent findings on neurocognitive functioning and health-related quality of life (HRQoL) of children after pediatric intensive care unit admission (PICU).

DATA SOURCES

Electronic databases searched included Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. The search was limited to studies published in the last five years (2015-2019).

STUDY SELECTION

Original studies assessing neurocognitive functioning or HRQoL in children who were previously admitted to the PICU were included in this systematic review.

DATA EXTRACTION

Of the 3649 identified studies, 299 met the inclusion criteria based on title abstract screening. After full-text screening, 75 articles were included in the qualitative data reviewing: 38 on neurocognitive functioning, 33 on HRQoL, and 4 on both outcomes.

DATA SYNTHESIS

Studies examining neurocognitive functioning found overall worse scores for general intellectual functioning, attention, processing speed, memory, and executive functioning. Studies investigating HRQoL found overall worse scores for both physical and psychosocial HRQoL. On the short term (≤ 12 months), most studies reported HRQoL impairments, whereas in some long-term studies HRQoL normalized. The effectiveness of the few intervention studies during and after PICU admission on long-term outcomes varied.

CONCLUSIONS

PICU survivors have lower scores for neurocognitive functioning and HRQoL than children from the general population. A structured follow-up program after a PICU admission is needed to identify those children and parents who are at risk. However, more research is needed into testing interventions in randomized controlled trials aiming on preventing or improving impairments in critically ill children during and after PICU admission.

Shorter rapid eye movement sleep duration in children with attention-deficit /hyperactivity disorder: the impact on quality of life

OBJECTIVES

The relationship of sleep with attention deficit hyperactivity disorder (ADHD) remains complex and unclear. The current study aimed to compare the subjective and objective sleep parameters among children with and without ADHD. Moreover, to address the effect of sleep parameters on the quality of life (QoL).

METHODS

We assessed 42 participants who were children with ADHD (aged 6-12 years), with predominant combined presentation (23), compared to 42 healthy children, who underwent a sleep study assessment subjectively (the Children's Sleep Habits Questionnaire), and objectively (one-night Polysomnographic recording). Also, parents completed the pediatric quality of life inventory (PedsQL-P).

RESULTS

Children with ADHD had more subjective sleep problems. ADHD patients also had a significant decrease in total sleep time and sleep efficiency, spending more time in wake and N1 sleep stages. Moreover, they had significantly lower rapid eye movement (REM)sleep duration and less duration of deep sleep stages. Multivariate regression analysis showed that REM sleep duration was the most contributing and predictive factor to QoL and school function impairment.

CONCLUSION

Children with ADHD have a significantly lower sleep quantity and poor sleep quality. In addition, short REM sleep duration independently contributes to further deterioration in different areas of QoL.

Sleep disturbances after pediatric traumatic brain injury: a systematic review of prevalence, risk factors, and association with recovery

STUDY OBJECTIVES

Sleep is vital for brain development and healing after injury, placing children with sleep-wake disturbances (SWD) after traumatic brain injury (TBI) at risk for worse outcomes. We conducted a systematic review to quantify SWD after pediatric TBI including prevalence, phenotypes, and risk factors. We also evaluated interventions for SWD and the association between SWD and other posttraumatic outcomes.

METHODS

Systematic searches were conducted in MEDLINE, PsychINFO, and reference lists for English language articles published from 1999 to 2019 evaluating sleep or fatigue in children hospitalized for mild complicated, moderate, or severe TBI. Two independent reviewers assessed eligibility, extracted data, and assessed risk of bias using the Newcastle-Ottowa Score for observational studies.

RESULTS

Among 966 articles identified in the search, 126 full-text articles were reviewed, and 24 studies were included (11 prospective, 9 cross-sectional, and 4 case studies). Marked heterogeneity was found in study populations, measures defining SWD, and time from injury to evaluation. Studies showed at least 20% of children with TBI had trouble falling or staying asleep, fatigue, daytime sleepiness, and nightmares. SWD are negatively correlated with posttraumatic cognitive, behavioral, and quality of life outcomes. No comparative intervention studies were identified. The risk of bias was moderate-high for all studies often related to lack of validated or objective SWD measures and small sample size. Heterogeneity precluded meta-analyses.

CONCLUSIONS

SWD are important morbidities after pediatric TBI, though current data are limited. SWD have implications for TBI recovery and may represent a modifiable target for improving outcomes after pediatric TBI.

Evidence Limitations in Determining Sexually Dimorphic Outcomes in Pediatric Post-Traumatic Hypopituitarism and the Path Forward

Neuroendocrine dysfunction can occur as a consequence of traumatic brain injury (TBI), and disruptions to the hypothalamic-pituitary axis can be especially consequential to children. The purpose of our review is to summarize current literature relevant to studying sex differences in pediatric post-traumatic hypopituitarism (PTHP). Our understanding of incidence, time course, and impact is constrained by studies which are primarily small, are disadvantaged by significant methodological challenges, and have investigated limited temporal windows. Because hormonal changes underpin the basis of growth and development, the timing of injury and PTHP testing with respect to pubertal stage gains particular importance. Reciprocal relationships among neuroendocrine function, TBI, adverse childhood events, and physiological, psychological and cognitive sequelae are underconsidered influencers of sexually dimorphic outcomes. In light of the tremendous heterogeneity in this body of literature, we conclude with the common path upon which we must collectively arrive in order to make progress in understanding PTHP.

Sleep Disturbances in Young Adults with Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life

OBJECTIVE

This study assessed the consequences of childhood traumatic brain injury (TBI) on sleep, fatigue, depression, and quality of life (QoL) outcomes and explored the relationships between these variables at 20 years following childhood TBI.

PARTICIPANTS

We followed up 54 young adults with mild, moderate, and severe TBI, and 13 typically developing control (TDC) participants, recruited at the time of TBI.

METHODS

Sleep was assessed with the Pittsburgh Sleep Quality Index and actigraphy.

RESULTS

At 20 years postinjury, results showed no significant difference between whole TBI group and TDC participants on subjective sleep quality; however, the moderate TBI group reported significantly poorer subjective sleep quality compared to those with severe TBI. Poorer subjective sleep was associated with increased symptoms of fatigue, depression, and poorer perceptions of General Health in the TBI group. Actigraphic sleep efficiency, fatigue, depression, and QoL outcomes were not significantly different between TBI and TDC or among TBI severity groups.

CONCLUSIONS

These preliminary findings underscore associations between subjective sleep disturbance, fatigue, depression, and QoL in this TBI sample, and mostly comparable outcomes in sleep, fatigue, depression, and QoL between the TBI and TDC groups. Further research is required to clarify these findings.

Sleep habits of children diagnosed with attention/ deficit/ hyperactivity disorder and effects of treatment on sleep related parameters

This study aimed to evaluate the baseline sleep habits of children with ADHD and the effects of treatment with methylphenidate (MPH) and atomoxetine (ATX) on sleep parameters. Treatment naive children with clinically normal intelligence diagnosed with ADHD were enrolled in the study. Children were treated naturalistically with MPH and ATX. Treatments were started at 0.5 mg/ kg/ day and titrated weekly to a maximum of 1.2 mg/ kg/ day. The daily equivalent dose was calculated according to clinician toolkits of Utah Academy of Child and Adolescent Psychiatry. DSM-IV Based Screening and Assessment Scale for Disruptive Behavior Disorders- Parent form (DBSASDBD) and Clinical Global Impression Scale were used to assess ADHD symptoms and Children's Sleep Habits Questionnaire (CSHQ)- Short Form was used to assess the sleep habits and problems before and after the treatment. Both MPH and ATX reduced symptom severity of ADHD in all domains and also reduced total CSHQ scores with similar effect sizes. (0.7 for MPH vs. 0.8 for ATX). The rate of clinically significant sleep problems at baseline was 93.5 %. At the end-point, 83.9 % of the sample still displayed clinically significant sleep problems while none of the children were judged to have moderate-severe sleep problems. Our results suggest that both ATX and MPH may selectively improve different sleep domains in children with ADHD. Studies using standardized dosing schemes for longer durations and evaluating sleep with objective measurements may clarify the differential effects of treatments on sleep among children with ADHD.

Sleep-Wake Disturbances After Acquired Brain Injury in Children Surviving Critical Care

BACKGROUND

Sleep-wake disturbances are underevaluated among children with acquired brain injury surviving critical care. We aimed to quantify severity, phenotypes, and risk factors for sleep-wake disturbances.

METHODS

We performed a prospective cohort study of 78 children aged ≥3 years with acquired brain injury within three months of critical care hospitalization. Diagnoses included traumatic brain injury (n = 40), stroke (n = 11), infectious or inflammatory disease (n = 10), hypoxic-ischemic injury (n = 9), and other (n = 8). Sleep Disturbances Scale for Children standardized T scores measured sleep-wake disturbances. Overall sleep-wake disturbances were dichotomized as any total or subscale T score ≥60. Any T score ≥70 defined severe sleep-wake disturbances. Subscale T scores ≥60 identified sleep-wake disturbance phenotypes.

RESULTS

Sleep-wake disturbances were identified in 44 (56%) children and were classified as severe in 36 (46%). Sleep-wake disturbances affected ≥33% of patients within each diagnosis and were not associated with severity of illness measures. The most common phenotype was disturbance in initiation and maintenance of sleep (47%), although 68% had multiple concurrent sleep-wake disturbance phenotypes. One third of all patients had preadmission chronic conditions, and this increased risk for sleep-wake disturbances overall (43% vs 21%, P = 0.04) and in the traumatic brain injury subgroup (52% vs 5%, P = 0.001).

CONCLUSIONS

Over half of children surviving critical care with acquired brain injury have sleep-wake disturbances. Most of these children have severe sleep-wake disturbances independent of severity of illness measures. Many sleep-wake disturbances phenotypes were identified, but most children had disturbance in initiation and maintenance of sleep. Our study underscores the importance of evaluating sleep-wake disturbances after acquired brain injury.

Traumatic Brain Injury, Sleep Disorders, and Psychiatric Disorders: An Underrecognized Relationship

Traumatic brain injury (TBI) is commonplace among pediatric patients and has a complex, but intimate relationship with psychiatric disease and disordered sleep. Understanding the factors that influence the risk for the development of TBI in pediatrics is a critical component of beginning to address the consequences of TBI. Features that may increase risk for experiencing TBI sometimes overlap with factors that influence the development of post-concussive syndrome (PCS) and recovery course. Post-concussive syndrome includes physical, psychological, cognitive and sleep-wake dysfunction. The comorbid presence of sleep-wake dysfunction and psychiatric symptoms can lead to a more protracted recovery and deleterious outcomes. Therefore, a multidisciplinary evaluation following TBI is necessary. Treatment is generally symptom specific and mainly based on adult studies. Further research is necessary to enhance diagnostic and therapeutic approaches, as well as improve the understanding of contributing pathophysiology for the shared development of psychiatric disease and sleep-wake dysfunction following TBI.